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HomeMy WebLinkAbout0046 ISLAND AVENUE - Health 46 ISLAND AVENUE, HYANNIS A= 265 021 r� I I 6 TOWN OF BARNSTABLE LOCATION �S`�.v.�l, � - SEWAGE# %TILLAGE ASSESSOR'S MAP&PARCEL (, So " 'c NAME&PHONE NO'�),,a ,, S— SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) \<ZjcExn NO.OF BEDROOMS OWNER'—� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching.Facility(If any wetlands exist within © 300 feet of leaching facility) C. Feet FURNISHED BY\ti\°��, NZ �. �1�'C �V� ` C l a � � 1 I cl I W v 1 .91 Ll (� � � S ASSFS$OR'S MAP NO. PARCEL 0 Z 1 UO' c A*1 ION S E W A G E PERMIT NO. V1-LLACE INST ALLER'S NAME A ADDRESS 3-'�- 9t-,fte ll s S 8 U I L D E R OR OWNER DATE PERMIT ISSUED 7�t DATE COMPLIANCE ISSUED O� Commonwealth of Massachusetts N v Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis Ort required for Y p MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the I computer,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name r� P.O. Box 371 Company Address Sandwich MA 02563 City/Town State Zip Code 508-888-6055 SI 12843 4 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority September 16, 2011 Inspect s Signature '- Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP The original should be sent to the system owner and copies sent to the buyer, if applicable=-and-#he�approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address howthe system will perform in the future under the same or different conditions oflus�. ua t5ins•09/08 Title 5 Official Inspection Form:Subsurface S� ge Disposal System•Page 1 of 1 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis ort MA 02647 September 14, 2011 required for y p p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not de/tructurally " (Y, N, ND) f the following statements. If"not determined," please explain. The septic tank is metal and over 20 yeor the ptic tank(whether metal or not) is structurally unsound, exhibits substantiion o exfiltration or tank failure is imminent. System will pass inspection if the existing tank ied h a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspectiotructurally sound, not leaking and if a Certificate of Compliance indicating that the tank is l20 years old is available. ❑ Y ❑ N ❑ ND (Exlow): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is required for Hy p annis ort p MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced 0//� ❑ N ❑ ND (Explain below): ❑ obstruction is removed /� Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or repl pe/ ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): J C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health/safety or the environment. 1. System will pass unless Board of I alth determines in accordance with 310 CMR 15.303(1)(b)that the system is not fu ctioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3 �_ 1 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 46 Island Ave. Property Address Bruce &Denise Johnson Owner Owner's Name information is required for Hy p annis ort MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary tq a surface water supply. ❑ The system has a septic tank and SAS and the'SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and,the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the kS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water an ysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other ailure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-?age 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is required for Hyannisport MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of,a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"t ach of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet f a surface drinking water supply ❑ ❑ the system is within 200 et of a tributary to a surface drinking water supply ❑ ❑ the system is located ' a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a apped Zone II of a public water supply well If you have answered "yes"to any que ion in Section E the system is considered a significant threat, or answered "yes" in Section D abov the large system has failed. The owner or operator of any large system considered a significant thr t under Section E or failed under Section D shall upgrade the system in accordance with 310 C 15.304. The system owner should contact the appropriate regional office of the Departmen r t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis ort required for Y P MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1098 GPD t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Island Ave. Property Address Bruce& Denise Johnson Owner Owner's Name information is H annis Ort required for Y P MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection. D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2009= 224 GPD 2010= 426 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: 1 Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the T' le 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis ort required for Y P MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No previous records found Was system pumped as part of the inspection? ® Yes ❑ No 00 If yes, volume pumped: 15 15gall0 How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis ort September 14, 2011 MA 02647 required for Y P every page. City/Town State Zip Code Date of Inspection D. System information (cont.) Approximate age of all components, date installed (if known) and source of information: Septic tank and d-box installed Nov. 1999. Leach pits installed May 1986. Certificates of Compliance. on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 118"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 11.5'X 5'X 4.5' 1500 gallons Sludge depth: 6" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 :r Commonwealth of Massachusetts W Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis Ort required for y p MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 8"at outlet Distance from top of scum to top of outlet tee or baffle 9„ Distance from bottom of scum to bottom of outlet tee or baffle 5" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee in place. Outlet concrete baffle in place. Liquid level is at outlet invert. Risers bring covers within 6" of grade. Tank is located under brick patio. Tank was pumped and cleaned after inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fi erglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top f outlet tee or baffle Distance from bottom of scum o bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts N W Title 5 Official Inspection Fora a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis Ort required for Y P MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural,integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: i ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i� i Dimensions: f/ Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Cfficial Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Island Ave. M Property Address Bruce & Denise Johnson Owner Owner's Name information is required for Hyannisport MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet,two outlets. No high water staining over outlet inverts. Equal flow. Roof drain runs through d-box riser. No sign of leakage. Riser puts cover just below bricks. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 46 Island Ave. Property Address Bruce &Denise Johnson Owner Owner's Name information is H annis ort required for Y P MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-1000 gal.w/2' stone ea. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits located and inspected with camera. Clean stone visible through side walls. Liquid level 3' below invert in#1, 3.5' below invert in#2. One it located under brick patio, other is in driveway. No sign of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is required for Hyannisport MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis Ort required for Y p MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 01' ��_ 33,E 30` i O `�� o 3 \ .- � — 1 \ i 1 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is H annis Ort required for Y p MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑. Shallow wells Estimated depth to high ground water: >2feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1986 + 1999 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole found no ground water to 12' (1983). Base of#2 leach pit 10' below grade. Slope to water on back side of propery drops below base of leach pits. Accessed local ground water contours and topo mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 46 Island Ave. Property Address Bruce & Denise Johnson Owner Owner's Name information is required for Hyannisport MA 02647 September 14, 2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 17 of 17 SIVNEN BOYLE a ASSOCIATES 42 CANTERBURY LANE-EAST FALMOUTH,MA 02536 Phone(508}540-2534-Fax(508)-540-2534 Attorney Martin J. O'Malley 336 South St. Hyannis,MA 02601 Re:461sland Ave.Hyannisport, Sewage Permit No.86-406 Property Owner: Martin J.O'Malley Assesors Map 263 Parcel 21 Dear Attorney O'Malley: The compliance order issued by the Barnstable Health Department on May 22, 1986 for Sewage Permit No. 86406 show two leaching pits located at your property having more than adequate design flow capacity for a five bedroom dwelling. The required flow for five bedrooms is 550 gallons per day, the existing leaching structures have a total design flow of 1,098 gallons per day when applying the design flow criteria in effect at the time of your system installation. J 4 y ;V- x ;+d 0F' � OF t Sincerely, ®��''� �4GIStERF�r���&-� ��h�' � �► STEP HEN ti ® J. a i WILLIAM C4 DOY E v3;A �, L)EBERMAN � No. 37559 �� o���No. 2387�O� Stephen J Dovl S �kS54. P �a° fir TEM Will fd Leber an PE Conunonwealth of Massachusetts Executive Office of Enviroranental Affairs UV Dept. of Environmental Protection ,Jolui Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box2119 Teaticket, MA 02536 (508)564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION M aP a,-s P. ca L 3 Property Address: 46Island Ave.Squaw Island Hyannis Port Address of Owner: Date of Inspection: 8/24198 (If different) Name of Inspector: John Graci O'Malley:336 South St.Hyannis 02601 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name, Address and Telephone Number:. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training,and experience in the proper function and maintenance of on-site sewage disposal systems. The system: This Inspection Is based on criteria defined In Title V x P855e5 _ code 310 CMR 16.303.My findings are of how the system is _ Conditionally Passes performing at the time of the inspection.My Inspection does _ Needs ur her Evaluation By the Local Approving Authority not imply any warrsntyor.gusranteeof the longevity ofthe sep0c system and arty of its components useful life. Fails 9 V Date: 8124198 Inspector's Signature: / RECE VEO ®\, The System Inspector shal submit a copy of this inspection report to the Approving Author�ty`within6tl4ifrb(30lays of co�mpl aag this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greatelr,ct6e i or hefn o me'i shall submit the report to the appropriate regional office of the Department of Environmental Protection's The original should be sent to the system owner and copies sent to the buyer,if applicable and=the app'i��ii BH0rllWdAW. Al INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or eAltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 007197) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 island Ave.Squaw island Hyannis Port Owner: O'Malley:336 South St.Hyannis 02601 Date of Inspection:8124198 _ Sew.aae backup or breakout or high static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised WNW) (revised 040197) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 46 island Ave.Squaw Island Hyannis Part Owner: O'Malley:336 South St.Hyannis 02601 Date of Inspection:9124198 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. __ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x _ Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is — — unacceptable)[15.302(3)(b)] i (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 46Island Ave.Squawlsland Hyannis Part Owner: O'Malley:336 South St.Hyannis 02601 Date of Inspection:9124199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x _ The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddress: 46Island Ave.Squaw Island Hyannis Port Owner: O'Malley:336 South St.Hyannis 02601 Date of Inspection:8124108 FLOW CONDITIONS RESIDENTIAL: Design flow:bso g•p•d./bedroom for S.A.S. Number of bedrooms: 6 Number of current residents: 1 Garbage grinder(yes or no): Yea Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: nia COMMERCIAL/INDUSTRIAL: Type of establishment: nia Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: r9a TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: I0 ye aw s Sewage odors detected when arriving at the site:(yes or no) No (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 461stand Ave.Squaw Island Hyannis Port Owner: O'Malley:336 South St.Hyannis 02601 Date of Inspection:6124198 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x con create—meta l_FRP_Polyethylene—other(explain) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: 1.816"H57"w4'110^ Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:25" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle:0 How dimensions were determined: measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound and functioning properly.Recommend pumping every two years. GREASE TRAP:_ (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_Polyethylene_other(explaln) Dimensions: Na Scum thickness:Na Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: Na Date of last pumpingiil, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Na BUILDING SEWER: (Locate on site plan) Depth below grade: 2-6" Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction Iin00- Diameter: 4" (,emmcrii:;. (con(filions of joint:,,ventilig,evidonce of leakago,etc.) (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46Island Ave.Squawlsland Hyannis Port Owner: O'Malley:336 South St.Hyannis 02601 Date of Inspection:8124198 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: n1a Type: leaching pits,number: two 1000 gallon leach phs leaching chambers,number:n1a leaching galleries, number: nla leaching trenches, number,length: rva leaching fields, number, dimensions:nia overflow cesspool,number:nia Alternate system: rya Name of Technology:_nra Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) Leach pits and all components are structurally sound and functioning properly.One leach pit was unacceasable,because It Is under the driveway. CESSPOOLS:_ (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: nia Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: nia Materials of construction: rUa Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) n1a Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n1a PRIVY:_ (locate on site plan) Materials of construction: nia Dimensions: n1a Depth of solids: nra Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n1a (revised 04127)97) ° R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 40 Island Ave.Squaw Island Hyannis Port O'Malley:336 South St Hyannis 02001 8124198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I� 1--i 6 O IN �l AC ivy AO hA 6c 3a r� aeviaed04rrr197) Pape ! of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 48 Island Ave.Squaw Island Hyannis Port O'Malley:338 South St.Hyannis 02601 8124198 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts (revised04)27197) page 10 of 10 �w OWN F B STABLE LOCAMN. ��1. SEWAGE E AGE # VILLAGE'- �' �� (.�V ASSESSOR'S MAP& LOTS S' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACrr tow ITY (type LEACHING FACIL e) �� (size) C� NO.OF BEDROOMS l BUILDER OR OWNER PERMIT DATE: COMPL CE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Furnished by ��� (�,(aU Feet F N Q cc,Q' R ¢ oe to S �9 V a ASSESS ORS jKAP N0: a 6 No.-•--�•b1.� PARCEL NO.: - �� Fim .... .'-. oap' THE CO `►J -MF,ISSACHUSETTS BOAR® OF HEALTH ..... ....................._...........O F...............................................-•------.-----••-----......_....----....--- Appliratiun for Uisvuuttl Morks TonDtrnr#lun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (✓ ) an Individual Sewage Disposal System at: ....L.(---- : J .. ..... .......... .... -- - -.- -- Location- c�d ss or Lot No. .............. Ai4.Tr.!11...-...:i:._..Q.,461. e ................. . .................................................................................................. Address W � Installer Address - d Type of Building Size Lot.............t.CY20.....Sq. feet V Dwelling—No. of Bedrooms-_A;?.^..2...:b:?.q.............Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............I............... Showers ('3 — Cafeteria ( ) Q' Other fixtures ...................................................... W. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity......__....gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No............:........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ •-----•--• -•----------------------------------------------------------------------......................................................... Descriptionof Soil._...__._$_R'Nf .........................•.................................................................................................................... x w U Nature of Repairs or Altera sons—Answer when applicable.................................. ......................:..:.................................. - - --------if-Rb•A*Xif-----•--+.A A.------. Agreement: r-_XPA! t-e4 cA /NC( Tp Yc-o NVO4 A4 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of AITIU 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed. •--. -- •--------• ------ `. .... -•--------- ... ApplicationApproved By•••-•-•-••--•.................... •-•• ... ...... ........................... -----•-•----• ..... Da e Application Disapproved for the following reason : -•--•-••----•••••••--••-•••••••-•--•••-••--•••---•--••......----••..............•••-•------ --•••----------- ----•-••-•.....•-••••-•••-----•-•------•---••-•-----•••••••------•--------•------••..................•- Date PermitNo......................................................... Issued........................................................ Date 6S No......�6.. L�� of....... �� Fxs........J............ Z THE COMMONWEALTH�OF MASSACHUSETTS BOARD OF HEALTH ....... .... .:... ....................OF.......................................... Appliration for Bhipoottl Works Tonotrnrtion rumit Application is hereby made for a Permit to Construct ( ) or Repair (✓) an Individual Sewage Disposal System at: y Is...IAtia( A. �f - _... - ••....-- --.--•... ................................ .......----•--•-----•--•••---••....-----•........................---.............................. Location- ddress or Lot No. MA R T,v J � A.G.L ------•.......... .....................•---..............---•-------•--...-•---.................................._..-•• _... Owner Address W Installer Address Type of Building Size Lot.........t 5r.C-(no.:tSq. feet Dwelling—No. of Bedrooms.�.?C^!�...2__-+�--q.............Expansion Attic ( ) Garbage Grinder ( ) �`4 Other—Type T e of Building No. of persons ............... Showers YP g ----•-----•----------------- P (3 ) — Cafeteria ( ) dOther fixtures .----•--------------------------------••--------------....------------------------......----------•--••-•-•--•--------•---...•--................_..... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter...----......... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.................................... ................. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------------------------------------------------------------------------------------------------------•--------...--••--......-•-•-..._.. D Description of Soil......... .&N.4----•----•-----------•-----------. x - U •--.........-•----•----------------•---•--...-••....-••-----••-------------•--------•--••--.....-•---•---------.....•------------•-----••-------•-•---......--------------...........------------•-----. w ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•_..... U Nature of Repairs or Alterations—Answer when applicable.........................................................:..:.................................. ---------- � / z =t3 zj...... 1�� E3 2 y ' L c� �� .......JFT-rrt--- Agreement: CXt0rlrv,5.( LrgCdi <<V 70 Co�v p� .y The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'LIE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed------.'} r� f' '� .............. --•-I.. -� - ----•-•---•---- Dat Application Approved BY.................................................�..... ... .....- -•-•-•-•-•-- ---?-.��._.. Dat Application Disapproved for the following reasons.. --•----------------•-----•--•-----....---.........--------....----------......... -- ..........---- -----•...................•--................-•--•-•------•-•-•---------------••------------•-••-----...--•-----------.............-••-•----•-•--.._...•--•-----•-------••----------------------••---••-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD EALTH ..........................................O F......................... ................................ CIrrtif irate of Tontpliatta THIS IS TO CERTIFY, That the Individual Sewag isposal S em constructed ( ) or Repaired) _..`. ^'� \ Inst 11, G - `I ���1!1 N at .............•----•------- -------•..... 1 ly:... © ....................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......� _.9_�6.............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI .N SATISFACTORY. 3,.,•. DATE........... . /... -.... .....- Inspector• `= - - c 'SPPT,L �(A }-1 THE COMMONWEALTH OF MASSACHUSETTS (��<ZS A� 11``�d� Y L 1'>ft 16 t�J fj — BOARD OF HEALTH eJr. OF..................................................................................... No...... �. C2.G......1+06 F$$..- ......... Disposal Worko Tonfrurtion ermit Permission is hereby granted................ .............................� t ` e •-•-----•---................................................................................. to Construct ( ) or Repair ) n Individual Sewage Disposal System at No.-------- ....... ........�_..�.(.............=��ri4 t+ �l•------A_1+ 6-----•-----Hy- -4kVwts ���� ....... Street as shown on the application for Disposal Works Construction Permit Dated............. .'_1.�. ............ 1 Board of a Ith DATE.................... FORM 1255 A. M. SUL IN. INC.. BOSTON j - L'tD C Al ION SEWAGE PERMIT N0. V I"L .A G E y�'a�t<rr _ IN:STA LLER'S NAME & ADDRESS BUILDER OR OWNER v I I DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ! �� ��` r� %9 4 m�� ,\ 4 e�� V <<(1F. :� 4 '� r 1, 4 �� �� � / �� Jv , " � t 9 , , �J �� ; I /� ��i } �S� � � � - No.�.�-.��S Fps... ...._............._ 'R THE COMMONWEALTH OF MASSACHUS9TTS BOAR® OF HEALTH ...........................I.....OF................................. Appliration for Utsp aa1 Work.5 Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (111*'an Individual Sewage Disposal System at: / f� / ..... . VV ...., ��..rC�ct..------ �---•-------------M ---f 9.Z, 3..--•-----••--...... ---- --------------.......................--------- Location-Address or Lot No. t A,0j er Address ler Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.-- ...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures --- ----------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (. ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P1 ------••-------------•---••---------------..... ............................................................................................................. 0 Description of Soil........................................................................................................................................................................ x U ------------------------------------------------------------------------------------------------------------- ---- -- -----•--•-- --------* of Repairs or Alterations—Answer when applicable.... ��.----.-.-s?®o-_-.. lC.-...._ f' ` � f �` /'y l��' --------------------------------------------------------------------------•-------------•-•----------------.....-----•----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI ILS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed-----/Sf, i ...... Date Application Approved By........... �,,e.t � ----------------------------•--.. ,��-d . 0...----- Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------•-----------•--........._ ....................•-------------...---...-----...........------------------------------............-----------------•-•------------------•----------------------------•-••----•--•-----------......_._ Date PermitNo......................................................... Issued_....................................................... Date i No.G . :22 5.. Fss.. 1...... 4- THE COMMONWEALTH OF MASSACHusrATTS BOARD OF HEALTH ...............................--..----....O F.......................................--.---............--------..._...........__....._.. ApplirFatiou for Uiipnsaal Viarkii C onstrurtinrt Vamit Application is hereby made for a Permit to Construct ( ) or Repair (41-1(an Individual Sewage Disposal System at: .............. .._... fl •' ............-'-'--....._................................................. �Lo cation o�Address or Lot No. -• Anstaller er -----------------------------------••----...Address W ..... .... .....�.... .-- ------ --------------------------------------------- dr� � Address dType of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms.__-.................... .Expansion Attic ( ) Garbage Grinder ( ) Other'—Type of Building No. of persons............................ Showers — Cafeteria p' Other fixtures -----------------------------•-• . -- . w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No...................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......... •--••-••-•----------------------------------------••----........ Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------------------•----------------------------------...................................---•---------•----•--•------•--•------•-------•---.----- 0 Description of Soil............................•--•---------------•------•----..................---------------------------------------------------------------------...------------------. x w x ..................................................... ----------- ------------------•---- -------------------- • - U Nature of Repairs or Alterations Answer when applicable / . :__________��Q_o___.._ <. ............. � .._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT I E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. / SignedU., ...... �- / d ? Date, Application Approved By........-•• _t ✓r' -----------------------•------- ---......,.T! Ke._:�, ;........ fiate Application Disapproved for the following reasons-----------------------------------=---------------------------•--------------------------------•---------------• ------------------••------------------••-•••-----•-•-----------------------•--•--•----------------•----•---•-------------•-------•-•------•--•--•••-------•-----•-••----•-----•--......-•----•----..._.. Date ' PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH `OF MASSACHUSETTS BOARD OF HEALTH ................................I.........OF..................................................................................... TntifirFatle of TomptiFaurr • �>�.� �.. .. ... . . . ...•---_-- .__._._-p.__._-....System constructed ( ) or Repaired (!,�' by...T f�r TO RTIFYThat,the -Sewage Disposal --•--------------------------------------------------•---•------------- at..... Ins . ' ..... = '�`j..................................... -------•--------------------------- ------•------•-----•---•------------- ------- has been installed in accordance with-the provisions of TIT Iyi 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... .--_�"_-�� 9 .__-_....... da.ted_.....5....................................... THE ISSUANCE OF.THIS CERTIFICATE SHALL NOT BE CONSTRtJED AS A GUARANTEE THAT THE SYSTEM WtL FU- TION SATISFACTORY. DATE...-".1 Inspector. ---------------------------------------•----•--••---•-•......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................OF..................................................................................... No. -� FEE. °............... �i��r�a��t1 �r�� �tra�rtirrn rrmit Permission.is hereby-granted......... :_. 11.G4 ---- ............... ....... to Construct ( or Repair ( -ap Individual Sewage Disposal System ..��.. 1 ::.... -----------•--•------------•-------•---------------------------•------.------- 9 ✓ Street as shown on the"application for Disposal Works Construction.Permit No__________ Dated........................................ Board of Health DATE.-- "� ---� • FORM 1255 HOBBS & WARREN, INC., PUBLISHERS. LOCATION . "'- SEWAGE PERMIT NO. 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